Clinical Faculty (MD) Application Form

Fields denoted by an asterisk (*) are required.

Personal Information
Name Name First Last
Primary Email
Primary Phone Primary Phone - ### - ### ####
Do you have a Western/Student ID number?

Do you have a Western/Student ID number? Yes No
Western/Student ID#
Practice Information
Practice Name
Practice Address Practice Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Practice Phone Practice Phone - ### - ### ####
Practice Fax Practice Fax - ### - ### ####
Practice Email Address
Do you have a Medical Professional Corporation?

Do you have a Medical Professional Corporation? Yes No
Corporation Name
Incorporated Business Number
HST

HST Yes No
HST Number
Is your Incorporated address the same as your practice address above?

Is your Incorporated address the same as your practice address above? Yes No
Incorporation Business Address Incorporation Business Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Please indicate your preferred method for being contacted for information and rotation requests.

Please indicate your preferred method for being contacted for information and rotation requests. Phone Fax Email
Home Information
Home Address Home Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Practice Specialty
Please select the Department(s) you are applying to:

Physicians practicing Emergency Medicine as their main practice may choose to apply with either and/or the Department of Family Medicine or the Department of Medicine

Please select the Department(s) you are applying to:

Physicians practicing Emergency Medicine as their main practice may choose to apply with either and/or the Department of Family Medicine or the Department of Medicine Anaesthesia Clinical Neurological Sciences Family Medicine Medical Imaging Medicine Obstetrics & Gynaecology Oncology Ophthalmology Otolaryngology Paediatrics Pathology Physical Medicine & Rehabilitation Psychiatry Surgery
Please indicate your practice specialty and where applicable your subspecialty.
By selecting Family Medicine or Medicine, Emergency Medicine can be selected within the PGY 3 Training Specialty or Subspecialty field
CNS Practice Subspecialty
PGY3 Training Specialty
Medicine Practice Subspecialty
Obstetrics & Gynaecology Practice Subspecialty
Oncology Practice Subspeciatly
Paediatrics Practice Subspecialty
Pathology Practice Subspecialty
Psychiatry Practice Subspecialty
Surgery Practice Subspecialty
Applicant Statement of Intent/Accomplishment
In becoming an Adjunct Professor, you will be expected to participate in academic scholarly activities. What teaching, research, leadership and/or other academic activities do you want to accomplish and/or participate in the Department?

In becoming an Adjunct Professor, you will be expected to participate in academic scholarly activities. What teaching, research, leadership and/or other academic activities do you want to accomplish and/or participate in the Department? Large Class Teaching Small Group Teaching Clinical Supervisor of Undergraduate Students Clinical Supervisor of Postgraduate Residents Research supervisor of Undergraduate Students Research supervisor of Postgraduate Residents Examiner (e.g., OSCE, CCFP, RCPSC) Curriculum Development Accreditation Education Administration (e.g. participation in Committee) Administrative Role (e.g. Academic Director, Course Coordinator) Peer Review Publications Publications of guidelines/policies Attend Faculty Development Workshops to augment academic skills relating to teaching, leadership, management, etc. Classroom Teaching Have medical learners in my practice Bedside teaching in the CTU Develop my teaching skills Coach medical learners Mentor medical learners Conduct independent research Quality Improvement project facilitation Annual Skills Day Portfolio Clerkship involvement Clinical Science/Summer Electives Simulation Evaluations Teach UME Teach PGME Teach Continuing Medical Education for Peers Teach Continuing Medical Education for Allied Health Professionals Other Activity, please explain Other Activity, please explain
What support from the Department, Windsor Campus, Distributed Education and/or Schulich would you want in order to accomplish these academic activities?

What support from the Department, Windsor Campus, Distributed Education and/or Schulich would you want in order to accomplish these academic activities? Teaching Development Seminars/courses Continuing Professional Development courses Leadership development Mentoring Academic Career Planning assistance Research opportunities/availability Department Connections with Schulich/Western Access to involvement in Department/Schulich administrative committees Other Supports, please explain Other Supports, please explain
License Information
CMPA Number
CMPA Effective Date CMPA Effective Date / MM / DD YYYY
FRCPC, Year Completed
CCFP, Year Completed
RCPSC Specialist, Year Completed
CFPC Specialist, Year Completed
CPSO Number
CPSO Effective Date CPSO Effective Date / MM / DD YYYY
Restricted CPSO License

Restricted CPSO License Yes No
Describe Restriction
Restriction Effective Date Restriction Effective Date / MM / DD YYYY
Restriction Expiry Date Restriction Expiry Date / MM / DD YYYY
Other
Attestations
Are you a Canadian Citizen?

Are you a Canadian Citizen? Yes No
Please attach Permanent Resident/Work Permit Information

Attach Files
Are you legally entitled to work in Canada?

Are you legally entitled to work in Canada? Yes No
Please explain
Are you a member in good standing with the College of Physicians & Surgeons of Ontario (CPSO)?

Are you a member in good standing with the College of Physicians & Surgeons of Ontario (CPSO)? Yes No
Please explain
Have you been disciplined by a professional licensing body?

Have you been disciplined by a professional licensing body? Yes No
Please explain
Have there been any decisions made against you by a professional licensing body?

Have there been any decisions made against you by a professional licensing body? Yes No
Please explain
Have you entered into an agreement with, made a promise to, or given an undertaking to a professional licensing body in the face of a potential disciplinary action by the body?

Have you entered into an agreement with, made a promise to, or given an undertaking to a professional licensing body in the face of a potential disciplinary action by the body? Yes No
Please explain
Have you been found guilty of a criminal offense in Canada or elsewhere relevant to your suitability to practice medicine?

Have you been found guilty of a criminal offense in Canada or elsewhere relevant to your suitability to practice medicine? Yes No
Please explain
Education Information
Medical School
Specify Other Medical School
Residency School
Specify Other Residency School
If you attended Western University, please provide your Western ID:
Hospital Information
Hospital Privileges

Hospital Privileges Yes No
List the name of the Hospital(s):
Hospital Name One
Hospital Name Two
Hospital Name Three
Have you had your privileges to practice in a hospital revoked, withdrawn, or not renewed as a result of professional misconduct or incompetence or have you resigned your hospital privileges while under investigation in respect of such a matter?

Have you had your privileges to practice in a hospital revoked, withdrawn, or not renewed as a result of professional misconduct or incompetence or have you resigned your hospital privileges while under investigation in respect of such a matter? Yes No
Please explain
Research Experience and Interest
Are you interested in participating in and/or conducting Research during your next adjunct appointment?
(Discussion with the Chair of the Department is required before a Research appointment is
approved.)

Are you interested in participating in and/or conducting Research during your next adjunct appointment?
(Discussion with the Chair of the Department is required before a Research appointment is
approved.) Yes No
Have you participated in Research before?

Have you participated in Research before? Yes No
Please describe your previous Research experience.
Please describe your Research area of interest.
Please describe your Research training.
Have you completed Mandatory Training for Human Research through the Tri-Council
(TCPS2 CORE) or training through the Collaborative Institutional Training Initiative (CITI)?

Have you completed Mandatory Training for Human Research through the Tri-Council
(TCPS2 CORE) or training through the Collaborative Institutional Training Initiative (CITI)? Yes No
Will access to research funding be required?

Will access to research funding be required? Yes No
Will access to Western Research Ethics Board be required?

Will access to Western Research Ethics Board be required? Yes No
Will medical learners be assisting with your research and require supervision?

Will medical learners be assisting with your research and require supervision? Yes No
Teaching Experience and Interest
Why are you interested in Teaching?

Why are you interested in Teaching? Personal Satisfaction Recruitment of future colleagues Academic Affiliation Community Exposure Requirement for my current hospital/practice employment Other Other
If applicable, please expand on your selection.
Have you participated in teaching before?

Have you participated in teaching before? Yes No
Please describe your previous Teaching experience:

Please describe your previous Teaching experience: Classroom Teaching Attended Teaching Seminars Publications Education Research Contributions Awards Teaching Supervision Learners Teaching Related Activities Continuing Medical Education for Peers Continuing Medical Education for Allied Health Professionals Other Other
If applicable, please expand on your selection.
Practice Profile
Practice Name
Are you part of a:
Choose One Practice

Are you part of a:
Choose One Practice CHC FHT FHN FHO Group Practice Solo Practice Hospital Based (Emergency Medicine or Hospitalist)
If you belong to a CHC or FHT, please identify which one:
Please list the names of the physicians in your group practice clinic:
Is your office/clinic Wheelchair Accessible?

Is your office/clinic Wheelchair Accessible? Yes No
Is your office/clinic able to offer parking to learners?

Is your office/clinic able to offer parking to learners? Yes No
Do you use Electronic Medical Records?

Do you use Electronic Medical Records? Yes No
Are you willing to participate in vertical learning (clerk & resident at the same time)?

Are you willing to participate in vertical learning (clerk & resident at the same time)? Yes No
What non-physician staff do you work with?

What non-physician staff do you work with? Not Applicable Physician Assistant Occupational Therapist Registered Nurse Social Worker Physiotherapist Lab Technician Registered Dietician Nurse Pracitioner Other
If applicable, please expand on your selection.
Resources available to learners in your office include:

Resources available to learners in your office include: Computer Textbooks Medical Journals Internet CD ROM Up To Date Other Other
Expand on Learning Resources
Is an Orientation provided to the learner?

Is an Orientation provided to the learner? Yes No
Please indicate any specific focus of your practice:
Educational Supports
How can the Schulich School of Medicine & Dentistry enhance your experience as a preceptor?
Are there any obstacles that you have encountered as a preceptor?
Are you interested in pursuing any of the following?

Are you interested in pursuing any of the following? Leadership Development Continuing Medical Education Leadership Roles Faculty Development
Please define in what way you would like to receive faculty development. Check all that apply:

Please define in what way you would like to receive faculty development. Check all that apply: Lecture or workshop in your community Lecture or workshop on campus (London or Windsor) Independent learning resources (audio, video, CD-ROM, reading) Conference (attend in person) Conference call (audio, video) Distance Learning (Internet based) Small Group Discussion Self-Learning Project Mentorship (Coaching) Virtual group with peers interested in similar topics Peer Dialogue

(Peer Dialogue is a joint project between Continuing Professional Development, Undergraduate Medical Education and Postgraduate Medical Education. Peer Dialogue is a process by which feedback in teaching is provided by one's peers in order to build a cadre of excellent teachers across the continuum of education.)
References

Please provide "Practice" contact information for address fields.
Reference One Name Reference One Name First Last
Reference One Organization/Hospital/Practice/University/Academic Centre
Reference One Phone Reference One Phone - ### - ### ####
Reference One Fax Reference One Fax - ### - ### ####
Reference One Email Address
Reference Two Name Reference Two Name First Last
Reference Two Organization/Hospital/Practice/University/Academic Centre
Reference Two Phone Reference Two Phone - ### - ### ####
Reference Two Fax Reference Two Fax - ### - ### ####
Reference Two Email Address
Reference Three Name Reference Three Name First Last
Reference Three Organization/Hospital/Practice/University/Academic Centre
Reference Three Phone Reference Three Phone - ### - ### ####
Reference Three Fax Reference Three Fax - ### - ### ####
Reference Three Email Address
Current CV
Upload CV

Attach Files

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Western respects your privacy. The personal information collected on this form is collected under the authority of The University of Western Ontario Act, 1992, as amended, and is used for the purpose of consideration for an academic appointment for preceptor activities. Please direct questions about this collection, use, or disclosure of personal information to Associate Director, Human Resources, Schulich School of Medicine & Dentistry, 519-661-3459.

If you experience technical problems with this form, please contact the helpdesk 519-661-2111 x81377; Hours Monday to Friday 8:00-4:30

Clinical Faculty (MD) Application Form

Clinical Faculty (MD) Application Form

Personal Information

Practice Information

Home Information

Practice Specialty

Applicant Statement of Intent/Accomplishment

License Information

Attestations

Education Information

Hospital Information

List the name of the Hospital(s):

Research Experience and Interest

Teaching Experience and Interest

Practice Profile

Educational Supports

References

Current CV